One unanticipated impact of the new coronavirus has been symptomatology that can mimic a heart attack. Abnormal heart rhythms have been reported all over the world as side effects of the coronavirus, as described in a March 27 New York Times article, “A Heart Attack? No, It Was the Coronavirus.” In the April 13 article “Coronavirus and the Heart,” Harvard Medical School researchers revealed that subsets of patients with no underlying cardiac issues can develop heart muscle inflammation due to the infection.
During the COVID-19 pandemic, the ability in an outpatient setting for clinicians to rapidly rule out acute cardiac events requiring hospital admission, including for patients who may be infected with COVID-19, has been of paramount importance. Additionally, finding alternatives to hospital use during patient surges has been critical to reducing risks of infection and preserving utilization of hospital EDs for the highest acuity patients. Catholic Health Services of Long Island, Rockville Centre, N.Y., an integrated, six-hospital health system, has scaled clinical pathways to solve this conundrum for groups of patients presenting to the urgent care setting with cardiac symptoms during the pandemic.
Clinical Indication for ED Referral
Historically, urgent care centers on Long Island have sent patients presenting with moderate chest pain to the ED. Starting in February 2019, Catholic Health Services partnered with a prominent urgent care chain and leveraged a technology solution to develop a risk-stratified rapid cardiac evaluation pathway. Since the partnership began, this pathway has enabled access to more than 20 patients per month, increased market share and prevented hospital utilization for over 97% of patients seen through the pathway. Catholic Health Services scaled the RCE pathway throughout Long Island by using a central referral office.
Pathway Development and Referral Process
To risk stratify patients for the rapid cardiac evaluation pathway, Catholic Health Services’ clinical leadership, in collaboration with its urgent care partner, developed guidelines to identify chest pain patients whose clinical presentation and electrocardiograms do not align with those of patients experiencing heart attacks. The team identified a cardiology practice in Suffolk County, N.Y., where meaningful unmet demand for urgent cardiology care access existed, to serve as the initial site.
The urgent care partner refers qualifying patients to the cardiology office through a telephone call and, when appropriate, initiates a conversation between the referring and receiving physicians. In response to the pandemic crisis, as part of the referral process, the practice now screens patients for potential COVID-19 symptoms and any previous contact with the virus. As a patient travels to the cardiology office, the urgent care center transmits the patient’s EKG, progress notes, medical summary and insurance information through an electronic portal.
Patients exhibiting COVID-19 symptoms are initially evaluated through a telehealth visit. If it is necessary for the patient to be seen in person, the practice arranges a physician consultation using appropriate precautionary measures. The frictionless referral process enables patients to be immediately seen upon arrival to the cardiology office. Since implementation of the rapid evaluation pathway, referred volume from the urgent care site grew by approximately eightfold. While the chief complaints of these patients varied, the majority reported chest discomfort.
Scaling the Pathway
After initial success with the rapid cardiac evaluation pathway, Catholic Health Services of Long Island launched a multistakeholder work group that included representation from cardiology, practice management, service line leadership and the urgent care partner. During biweekly meetings, the work group discussed and troubleshot key issues, including appropriate risk stratification, performance indicators and the general tracking of patients seen through the pathway.
The team determined that to efficiently scale the program to other areas within the organization, a central office was needed to field inbound urgent cardiac referrals and route these calls to the practice. As the rapid cardiac evaluation pathway grew across geographies, the urgent care partner instructed its sites to call one central number to schedule the cardiac consults. Through the “one call solves all” model, the ease of remembering one number fosters the scalability and success of the program. Catholic Health Services was able to expand the rapid cardiac evaluation pathway to a new county within six months of starting the initial program, largely thanks to the use of one central phone number.
Top 3 Lessons Learned
Catholic Health Services learned several lessons while implementing the risk-stratified rapid cardiac evaluation pathway to better assess and manage cardiac patients. The pathway has served the organization well during the COVID-19 pandemic, when a subset of patients have been presenting with cardiac symptoms in addition to viral symptoms. Three of the top lessons CHS leadership learned were:
- Well-designed clinical pathways combined with timely diagnosis and management in the outpatient setting reduces avoidable ED utilization and fosters care coordination. Of the patients who traveled through the pathway, 97% avoided an ED visit while remaining in an integrated delivery network.
- Rapid outpatient cardiac pathways enabled CHS and its urgent care partner to risk stratify COVID-19 patients throughout the pandemic. Coronavirus patients can develop unanticipated cardiac conditions, which benefit from rapid specialist and telehealth access enabled through the rapid cardiac evaluation pathway.
- Sustainable scaling of a successful process can benefit from technological and operational innovation and high-touch, multi-stakeholder involvement. CHS scaled its clinical pathways throughout Long Island, leveraging cross-functional teams, a central referral office, and technology solutions for referral management and telehealth.
In additional to scaling the rapid cardiac pathway, the health system has since launched several new pathways across orthopedics and primary care, which build on these lessons. Reducing avoidable hospital use and more effectively risk stratifying patients will continue to be valuable techniques as the organization continues to navigate COVID-19 and beyond.
Vivek Taparia, FACHE, was previously deputy executive director, Catholic Health Services of Long Island, Rockville Centre, N.Y. (vtaparia@prohealthcare.com). Avni Thakore, MD, FACC, is CMO, Catholic Health Services of Long Island, a cardiologist at St. Francis Hospital–The Heart Center, Roslyn, N.Y., and an ACHE Member (avni.thakore@chsli.org).